Opioid use is a public health epidemic in the United States, resulting in more than 130 deaths due to opioid overdose every day (Centers for Disease Control [CDC], 2018). Arizona, like most states, has reported increasing opioid overdose rates and averages over 100 opioid overdose deaths each month. Among these deaths, 54% had at least one legal opioid medication prescription for chronic pain and 34% only used legally prescribed opioid drugs (Arizona Department of Health Services [AzDHS], 2018b). Chronic pain affects more Americans than diabetes, heart disease, and cancer combined with over 100 million people experiencing chronic pain (Gereau et al., 2015). Health care providers, from novice to experienced, care for many patients with chronic pain daily in their practices. In fact, the CDC reported nearly 20% of primary care visits are chronic pain related, yet primary care providers, including family nurse practitioners (FNPs), often lack knowledge about nonopioid pain management treatment such as integrative interventions (Dowell, Haegerich, & Chou, 2016).
The CDC reported, “some integrative interventions are evidence-based and should be utilized in managing chronic pain” (National Center for Complementary and Integrative Health [NCCIH], 2017). Education, faculty mentoring, and modeling are imperative to prepare future prescribers regarding chronic pain management (Institute of Medicine, 2011). Fellows of the Integrative Nursing Faculty Fellowship and faculty members at the University of Arizona supported the addition of integrative modalities for chronic pain management as a logical, evidence-based solution given the high rates of opioid misuse and addiction. Thus, the purpose of this educational innovation was to prepare future FNPs to use holistic integrative interventions to reduce opioid prescriptions in chronic pain management.
The current status of pain management in the United States can be traced to the 1980s, along with the maxim “pain is the fifth vital sign” (Tompkins, Hobelmann, & Compton, 2017). Table 1 outlines the opioid crisis timeline. Chronic use of opioid medications increased and became the standard of care as patients and medical providers believed that pain could only be managed by medications. By the 1990s, newly developed opioid medications became increasingly stronger and addictive resulting in more patients with chronic pain becoming addicted (Quinones, 2015). Most opioid addicts in this country became addicted with legally prescribed medications. Medical providers began to discontinue opioid treatments when the dangers of prescribing opioid medications for patients became clear. Unfortunately, most patients who were addicted wanted to continue with their opioid treatment, needing higher dosages to receive the same pain relief. This cascade of events caused many patients to resort to obtaining opioids through illegal means. Eventually, the pain did not ease with any amount of prescription opioids with the patient resorting to heroin use (Quinones, 2015). The Department of Health and Human Services (2017) reported that nearly 886,000 Americans are currently using heroin.
Heroin, as all opioid derived drugs, is made from the poppy seed. Heroin, hydrocodone, and oxycodone enter the brain rapidly and bind to dopamine receptors on cells located in many areas, especially those involved in feelings of pain and pleasure and in controlling heart rate, sleeping, and breathing (CDC, 2018). Although all opioids are addictive, heroin is extremely addictive. As with all opioids, the person becomes tolerant to the heroin and must increase the dose to receive the same results (CDC, 2018). This often results in overdose and without medical treatment death.
The current “opioid crisis/epidemic” interventions have focused on chronic pain management guidelines and recognition and treatment of substance use disorders (especially opioids and controlled substances). National initiatives, including task forces and guidelines, have been developed (National Institutes of Health, 2016). Risk Evaluation and Mitigation Strategy is a strategy required by the Food and Drug Administration to manage known or potential serious risks associated with extended release and long acting opioids to ensure benefits outweigh risks. Recent changes include medication-assisted treatment options. Medications, such as naloxone, are available to reverse the respiratory depression in an opioid overdose. Most states have allowed nasally administered naloxone (Narcan) to be available without a prescription at the pharmacy counter and those patients at higher risk should have naloxone readily available with education provided to friends/family members regarding use (AzDHS, 2018a). Currently, pharmacists are able to dispense naloxone, without a prescription, in 46 states (AzDHS, 2018a).
Another initiative is the Comprehensive Addiction and Recovery Act (CARA) of 2016, which temporarily expanded medication-assisted treatment and allows nurse practitioners (NPs) and physician assistants to prescribe buprenorphine/naloxone for addiction treatment. As part of CARA, NPs may apply for a DATA 2000 waiver through the Substance Abuse and Mental Health Services Administration (2018). After completing the required training, FNPs may prescribe buprenorphine/naloxone to 30 patients the first year and may then petition to treat up to one-hundred patients each year. Buprenorphine/naloxone can be a dangerous and addictive drug and is not a long-term solution for the opioid epidemic.
State-level initiatives have had similar objectives to national initiatives, including chronic pain management, guidelines that include prescription drug monitoring, reducing opioid use/misuse/abuse, and increased efforts to recognize and treat opioid dependency/addiction. The state of Arizona and the AzDHS addressed chronic pain management through the development of “The Arizona Pain and Addiction Curriculum” focusing on future prescribers in the following health care professions: medical doctor (MD), NP, doctor of osteopathic medicine (DO), dentists (DMD, DDS), pharmacy (MPharm and PharmD), and physician assistants. The curriculum vision is, “to redefine pain and addiction as multidimensional, interrelated public health issues that require the transformation of care toward a whole-person interprofessional approach with a community and systems perspective” (AzDHS, 2018a).
Chronic pain management is an increasingly complex issue and requires comprehensive treatment plans (CDC, 2018). Treatment should consider least invasive/intensive management strategies first and use interventions with increased intensity/more invasive if initial interventions are not successful (AzDHS, 2018a). Opioids should be considered only when multiple interventions have been tried without success and in select patients who meet criteria for safe utilization (AzDHS, 2018a).
The CDC (2018) estimates chronic pain is the initial complaint in 20% of all medical visits in primary care. The Joint Commission (2018) recently reported that nonopioid treatment options, including integrative therapies, are useful in reducing and eliminating opioids for chronic pain (CDC, 2018). Therefore, FNPs need to develop multimodal strategies, including integrative modalities, to manage chronic pain without overutilization of opioids.
Many respected medical groups have implemented guidelines indicating the usefulness of integrative interventions. The American College of Rheumatology's osteoarthritis guidelines include the following integrative interventions based on evidence: Chinese acupuncture, Tai Chi, and transcutaneous electrical nerve stimulation (TENS) units. Yoga improves pain tolerance and alters brain chemistry (Villemure, Čeko, Cotton, & Bushnell, 2015). The American College of Physicians released the following recommendations regarding low back pain management: massage, acupuncture, mindfulness-based stress reduction, Tai Chi, and yoga (Murthy, Sibbritt, & Adams, 2015; Wayne, et al., 2018; Westrom, Maiers, Evans, & Bronfort, 2010).
The University of Arizona, Doctor of Nursing Practice (DNP) Program, FNP specialty faculty were one of the first to initiate the Arizona Pain and Addiction Curriculum Guidelines within the DNP curriculum to prepare future FNPs to provide effective and safe chronic pain management. In the summer semester of 2018, the chronic pain management modules were redesigned to align with the Arizona Pain and Addiction Curriculum objectives. In addition, the DNP curriculum was redesigned and expanded to provide education about nonopioid integrative treatment options. The educational innovation used the Try-It-On teaching-learning strategy to introduce holistic integrative interventions to FNP students. The Try-It-On teaching-learning strategy was developed by the primary author and is based on holistic principles of viewing one's entire being as inseparable and interrelated and incorporates the Modeling and Role Modeling (MRM) theory, which emphasizes whole person care (Hertz, 1997).
The Try-It-On teaching-learning strategy encourages students to do more than complete an assignment as a task to check off, but to engage mentally, emotionally, and physically (Gregg & Twibell, 2016). If a medical provider does not believe an integrative therapy is effective, the patient will experience a decreased willingness to try a treatment and the overall perceived effectiveness will decrease. Try-It-On teaching-learning strategy promotes a hands-on immersion to encourage the students to personally experience integrative treatment modalities. When the student, as the stakeholder, believes in the effectiveness of an integrative treatment modality through personal experience, the student, as the health care provider, will be enabled to provide education to the patient that will positively influence patient outcomes. The student outcome is a shift in the perception from skeptical to open and finally to develop a personal belief in the effectiveness of an integrative modality, which is transferred to the patient. The Try-It-On teaching-learning strategy is partially based on the MRM theory, which relies on the underlying assumptions and philosophical beliefs regarding how people are alike and different, and how nurses influence patients (Hertz, 1997). The MRM theory encourages the nurse to understand the patient's perceptions and life experiences and develop personalized treatment plans from a position of mutual respect and understanding.
For this educational innovation, two learning modules were developed. Curriculum changes in the first learning module included expansion of the existing chronic pain management section. Additional topics developed were substance use disorder assessment, recognition, treatment options, and developing effective communication skills. The second learning module explored nonopioid options for chronic pain management through immersion within holistic integrative interventions.
Evaluation of the new curriculum used the Kirkpatrick Evaluation Model (2014). The Kirkpatrick Model consists of four levels: level 1 measures learner satisfaction, level 2 measures increased knowledge, level 3 measures change in behaviors, and level 4 determines if the material had a positive and long-lasting impact on practice (Kirkpatrick & Kirkpatrick, 2014). Our evaluation focused on intended behavior change, which aligns with the Kirkpatrick education level three (Kirkpatrick & Kirkpatrick, 2014).
The purpose of this educational innovation was to prepare future FNPs to use holistic integrative interventions and effective communication skills to decrease overprescribing of opioids for chronic pain management.
Within the FNP clinical management course, students were informed of the evaluation of content and gave informed consent by completing the pre and post participation evaluations. Students were offered 2.5 bonus credit points for completing each of the pre and post participation evaluations. Students were awarded bonus points on the honor system by emailing faculty stating they had completed the pre and post evaluations. This educational innovation, approved by the University of Arizona Institutional Review Board, was determined to be a program evaluation and not human participant research.
Two modules were developed and taught within the FNP specialty of the DNP Program. The chronic pain module addressed chronic pain management, substance use disorders, and effective communication skills. Assignments included recorded lectures, up-to-date CDC guidelines for pain management, voice thread assignments, and a small group case study via an online platform to build communication skills in working with chronic pain patients (Dowell, et al., 2016). Students in small groups (four to five students per group with a faculty) completed a case study focused on developing the skills to have an open and honest conversation with patients about the risks of addiction and death from opioid use. The case study included topics such as the etiology of pain, reducing opioid use, not starting opioid medication therapy, risks versus benefits of opioids, and how to control chronic pain through safer options. Novice FNPs caring for patients with chronic pain need to be prepared to discuss this difficult topic in an honest, respectful, and effective manner. It is necessary to educate the patient about the risks and alternatives without leaving the patient feeling judged or unheard.
The holistic integrative interventions module, the second module in the series, addressed nonopioid pain management options. The module contained four mini recorded lectures focusing on evidence-based integrative nonopioid pain management strategies: yoga/Tai Chi (Skelly, et al., 2018), meditation (Cherkin, et al., 2016; Cramer, et al., 2012; Reiner, Tibi, & Lipsitz, 2013), guided imagery (Pozadski & Ernst, 2011), massage (Kalichman, 2010; Perlman, et al., 2012), and acupuncture (Vickers, et al., 2012). These lectures included background for use and how to implement into practice through a hands-on approach. Each modality included a do-it-yourself video, with the exception of acupuncture. Students learned to manage chronic pain with a holistic focus through immersion within these integrative modalities.
The pre and post evaluation was comprised of 42 questions. Students were asked to rate on a 11-point Likert scale from strongly disagree (0) to strongly agree (10) comfort level in prescribing opioids, experience with chronic pain management and treatment options (Tables 2 and 3).
The three inquiries of “Have you heard of it?” (yes/no), “Have you tried it?” (yes/no), and “Would you use/prescribe for your patients?” (11-point scale ranging from extremely unlikely (0) to extremely likely (10) were used to address integrative modalities. The integrative modalities measured were biofeedback; chiropractic adjustment; yoga/Tai Chi; meditation; guided imagery; progressive muscular relaxation; acupuncture/acupressure; mindfulness; massage therapy; reflexology; herbal medications; and aromatherapy.
Thirty-three students completed the pre-evaluation and 35 completed the post evaluation with 27 students completing both pre and post evaluations. Given there were 44 students in the course, participation was 61%.
Overall, students were comfortable seeing chronic pain patients with a slight increase from pre to post evaluation (Table 3). Students agreed with the goal of chronic pain management and believed integrative therapies can work and are valuable. The statement addressing experience using integrative therapies and fear of prescribing opioids were midrange (4.67–5.50). Both increased slightly from pre to post evaluation suggesting an increased comfort level.
The students believed that chronic pain management was challenging and had quality-of-life effects on patients, with little change from pre to post evaluation (Table 3). The selection of approved and effective treatments increased from pre to post evaluation with the greatest increase for TENS unit and acupuncture. For both the pre and post evaluation, the majority of students (greater than 90%) would start with the least invasive interventions, include lifestyle and integrative interventions, and use interdisciplinary care in the treatment of chronic pain.
Other than reflexology, all the students had heard of the integrative therapies at pre-evaluation, with the majority (88.9%) having heard of reflexology. At the pre-evaluation, the students were likely to use/prescribe the integrative therapies with scores of six or greater (Table 4). There was an increase in the likelihood of using/prescribing each of the therapies, except massage therapy, from pre to post evaluation, with a significant increase for using/prescribing biofeedback (p = .038).
This educational innovation implemented holistic principles with a Try-It-On teaching-learning strategy to reduce opioid prescribing through increased communication skills and integrative alternatives for chronic pain management. Students reported an increase in personal comfort level managing chronic pain patients following the learning modules. The results of this educational innovation indicate increased base knowledge and exposure are both imperative for new provider buy-in. This combined knowledge increases the tools needed by future FNPs to navigate the opioid crisis/epidemic with evidence-based nonopioid strategies for treating chronic pain.
Students were more likely to report a willingness to personally try integrative modalities on completion of the coursework. This implied that students became interested in the modalities and the usefulness during the immersion experience. Students reported an increase in both personal use of integrative modalities and intent to prescribe these with patients. For most students, this was their first exposure to integrative modalities. With continued exposure, students are more likely to explore integrative care and implement into practice. These findings were similar to findings in a previous study regarding stress management strategies using integrative therapies (Gregg & Twibell, 2016).
There were several limitations to this educational innovation. Students were managing a very heavy workload during this semester with 180 clinical hours, implementing DNP Projects, and balancing other courses in addition to this primary clinical course. This may have decreased the overall time spent within the learning modules and integrative modalities. Students were also asked to complete the pre and post evaluations during the weeks of midterms and final examinations, respectively. This may have altered the time spent reflecting on the answers, which may have affected the outcome. Students were able to access the post evaluation without completing the pre-evaluation. Due to students earning 2.5 bonus points in the course for completing each evaluation, more students completed the post evaluation than the pre-evaluation. Those that only completed either the pre to post evaluation were not evaluated.
The small group case study was designed to have an open discussion focusing on effective communication skills. There were multiple faculties leading the small groups, which may have resulted in a different emphasis in the discussion. This learning opportunity will be changed for the next implementation to include more defined learning rubrics. This assignment will also be expanded to include more student practice using these communication skills. The learning modules have only been implemented into the course one cycle. The course will repeat in the summer of 2019 with updates.
Opioids have been over prescribed for managing chronic pain. Increased opioid use has created side effects, complications, opioid addictions, heroin addictions, and overdose deaths. The opioid crisis/epidemic is creating a burden on national, state, and local levels and has health care providers searching for effective, alternative interventions to replace opioids. Holistic, integrative interventions have been used for 100 of years all over the world and are considered effective in relieving chronic pain in many cultures. Most integrative interventions have anecdotal evidence considered “practice based,” but there is increasingly “evidence-based” information available regarding the effectiveness of integrative therapies in chronic pain. In fact, pain is the most common reason people report using integrative interventions (NCCIH, 2017).
Chronic pain management is a continued need and should include consideration for patient preference; treatment options with lower risks of side effects, complications, and addiction; follow state and national initiatives; and support professional organization guidelines. Faculty preparing future NP's have the moral obligation to prepare new providers with the skills and confidence to manage chronic pain patients with treatment options that will reduce the dependency on opioid medications.
Nurse practitioner educators have an opportunity to combat the opioid epidemic/crisis through the education of future prescribers. Students must be prepared with tools to provide safe, effective interventions for long-term, nonopioid chronic pain management, including holistic integrative interventions. This educational innovation effectively provided the basics of these skills. Future offerings of these learning modules would benefit from increased student engagement through more small-group activity. Students responded positively to the Try-It-On teaching-learning strategy to introduce holistic integrative modalities as treatment options for chronic pain. This response indicated value in experiential learning and should be considered when developing curriculum. Today's rapidly changing national guidelines targeting the opioid epidemic makes it imperative to target FNP students with immersive teaching strategies, such as this one for chronic pain management, with a focus on effective communication and holistic integrative interventions.
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